ACA & Health Benefits Compliance for Home Care Agencies in New York

Exchange. New York runs its own exchange, NY State of Health, which also administers the Essential Plan (Basic Health Program) used heavily by home care workers. Source ↗

Essential Plan cut to 200% FPL (July 1, 2026). With federal H.R. 1 funding cuts ending New York's 1332 waiver, Essential Plan eligibility dropped from 250% to 200% FPL on July 1, 2026. Roughly 450,000 New Yorkers - including many caregivers - lost EP coverage and must pick a qualified health plan by August 30, 2026; those who claim premium tax credits can now trigger 4980H(b) penalties for ALE agencies that don't offer affordable coverage. Source ↗

Medicaid expansion. New York expanded Medicaid; adults to 138% FPL qualify, with the Essential Plan covering 138-200% FPL at little or no premium. Source ↗

DBL + Paid Family Leave. New York employers must carry statutory Disability Benefits (DBL) coverage and NY Paid Family Leave insurance; PFL provides up to 12 weeks at 67% of wages (capped at a percentage of the state average weekly wage), funded by employee payroll deductions. Source ↗

NY Secure Choice - 2026 deadlines. The now-mandatory NY Secure Choice Savings Program covers private employers with 10+ employees, in business 2+ years, without a retirement plan. Registration deadlines: 30+ employees by March 18, 2026; 15-29 by May 15, 2026; 10-14 by July 15, 2026. Exempt employers must certify their exemption online. Source ↗

36-month continuation. New York's continuation law covers insured groups of any size and runs up to 36 months - double federal COBRA - relevant to agencies with fewer than 20 employees. Source ↗

No state 1095 reporting. New York has no state individual mandate or employer 1095 filing requirement; only federal ACA reporting applies. Source ↗

ALE threshold & counting caregivers. The ACA employer mandate applies to Applicable Large Employers (ALEs) with 50+ full-time equivalent employees (30+ hrs/week or 130 hrs/month). Home care agencies with variable-hour caregivers can use the IRS look-back measurement method (3-12 month measurement period plus a stability period) to determine which caregivers must be treated as full-time and offered coverage. Source ↗

2026 employer mandate penalties. For 2026, the Section 4980H(a) penalty (no offer of minimum essential coverage to 95% of full-time staff) is $3,340 per full-time employee minus the first 30; the 4980H(b) penalty (coverage unaffordable or not minimum value) is $5,010 per full-time employee who gets subsidized exchange coverage (Rev. Proc. 2025-26). Source ↗

2026 affordability percentage. Coverage is affordable in 2026 if the employee's self-only contribution does not exceed 9.96% of household income (up from 9.02% in 2025), per Rev. Proc. 2025-25. Employers may use the W-2, rate-of-pay, or federal poverty line safe harbors in place of household income. Source ↗

2026 FPL safe harbor. A 2026 plan automatically satisfies the federal poverty line affordability safe harbor if the lowest-cost self-only contribution is no more than $129.89/month ($15,650 mainland FPL x 9.96% / 12). Alaska and Hawaii use higher FPL figures (about $162.26 and $149.31/month respectively). Source ↗

1095-C deadlines (2025 forms filed in 2026). ALEs must furnish Forms 1095-C to employees by March 2, 2026, or use the alternative method under the Paperwork Burden Reduction Act: post a clear website notice and furnish a copy within 30 days of request. E-filing of Forms 1094-C/1095-C with the IRS is due March 31, 2026, and e-filing is mandatory for employers filing 10 or more returns. Source ↗

ICHRA as a compliance option. An Individual Coverage HRA (ICHRA) lets agencies reimburse caregivers' individual-market premiums tax-free and counts as an offer of coverage under 4980H. An ICHRA is affordable if the employee's cost for the lowest-cost self-only silver plan, minus the HRA allowance, stays within the 9.96% affordability threshold; employee classes (e.g., field caregivers vs. office staff) can receive different allowances. Source ↗

Enhanced premium tax credits expired 12/31/2025. The ARPA/IRA enhanced premium tax credits expired December 31, 2025, restoring the 400% FPL subsidy cliff. KFF estimates average subsidized marketplace premium payments more than doubled (about +114%) for 2026, making employer-sponsored coverage and ICHRAs more attractive to caregivers - and increasing the chance that full-time employees seek subsidized exchange coverage that triggers 4980H penalties for non-offering agencies. Source ↗